This document provides information on urinary tract obstruction, including its causes, symptoms, diagnosis, and treatment. It discusses obstruction that occurs in the upper urinary tract between the renal medulla and bladder, as well as lower urinary tract obstruction distal to the bladder. Common causes of obstruction include urinary calculi, tumors, strictures, benign prostatic hyperplasia, and extrinsic compression. Acute obstruction often causes flank pain while chronic cases can be asymptomatic. Treatment depends on the cause but may include drainage, drug therapy, or surgery.
This document provides information on urinary tract obstruction, including its causes, symptoms, diagnosis, and treatment. It discusses obstruction that occurs in the upper urinary tract between the renal medulla and bladder, as well as lower urinary tract obstruction distal to the bladder. Common causes of obstruction include urinary calculi, tumors, strictures, benign prostatic hyperplasia, and extrinsic compression. Acute obstruction often causes flank pain while chronic cases can be asymptomatic. Treatment depends on the cause but may include drainage, drug therapy, or surgery.
This document provides information on urinary tract obstruction, including its causes, symptoms, diagnosis, and treatment. It discusses obstruction that occurs in the upper urinary tract between the renal medulla and bladder, as well as lower urinary tract obstruction distal to the bladder. Common causes of obstruction include urinary calculi, tumors, strictures, benign prostatic hyperplasia, and extrinsic compression. Acute obstruction often causes flank pain while chronic cases can be asymptomatic. Treatment depends on the cause but may include drainage, drug therapy, or surgery.
Learning objtectives • You should – Recall urinary tract structure and function in understanding the effects of obstruction at different levels in the urinary tract – Understand how the rate of onset of obstruction influences symptoms and outcomes – Appreciate the impotance of benign prostatic hyperplasia and urethral stricture as treatable causes of urinary tract obstruction – Be aware that insidious onset can result in irreversible upper tract changes Upper urinary tract obstruction • Occuring at point between the renal medulla and the bladder lumen • Is usually unilateral, except with extrinsic cause, such as pelvic tumers, retroperitonium fibroblasis et al. • The renal pelvis and ureter above the level of the obstruction become distended ( hydronephrosis and hydroureter). The cause of obstuction • Intraluminal cause • Intramural cause • Extrinsic cause • Intraluminal cause – Calculus: by far the most common – Clot – Renal papillary necrosis • Intraluminal cause • Intramural cause • Extrinsic cause • Intramural cause – Urothelial tumour of ureter / of bladder – Congenital pelviureteric junction obstruction – Ureteric stricture – ureterocele • Intraluminal cause • Intramural cause • Extrinsic cause • Extrinsic causes – Ureteric injury, most often iatrogenic – Direct invasion from carcinoma of cervix, uterus, prostate or bladder – Retroperitoneal fibrosis, which may be malignant, inflammation or idiopathic – pregnancy • Acute obstruction usually cause loin pain but chronic obstruction can be silent • If bilateral may present with sign of renal failure (Uremia) • Pain in the flank radiating along the course of the ureter • Gross total hematuria • Gastrointestinal symptoms • Chills, fever, burning on urination, and cloudy urine • Uremia: nausea, vomiting, loss of weight and strength, and pallor • An enlarged kidney • Renal tenderness • Cancer of the cervix • A large pelvic mass( tumor or • pregnancy) • Ascites : • Laboratory findings • X-Ray findings • CT sonography MRI • Isotope scaning • Insrumental examination Treatment • Depends on the cause,but the dialated collecting system proximal to the obstruciton can be drained with a percutaneous cannula under ulrasound or radiographic control, to provide temporary relief of the obstruction • This protects renal function while the level and cause of the obstruction is determined and definitive treatment planned. • It also permits antegrade urography, which may be very useful in diagnosis. • If the cause is known to be untreatable pelvic malignancy, the decision to relieve obstruction needs to be taken with care, to avoid compromising best palliation. Lower urinary tract obstruction • Obstruction occuring distal to the bladder (intravesical obstruction) causes voiding difficulty initially. • Such bladder outflow obstruction is very common and of great impotance in urology. Causes • Acquired causes in adult may be structural: – Urethral stricture – Benign prostatic hyperplasia – Carcinoma of the prostate – Other pelvic tumour – Bladder neck hypertrophy • Or functional: – Bladder neck and sphincter dysynergia Prostate: benign hyperplasia • Benign prostatic hyperplasia (BPH) is detectable in nearly all men over the age of 40 years, and in later years some degree of bladder outflow obstruction will often develop as a result. • Is the most common cause of bladder outflow obstruction in men. • Currently only one in 10 men come to require surgical treatment, but with the advent of potentially effective drug therapies, both symptomatic presentation and treatment rates are rising Clinical features • The clinical presentation of bladder outflow obstruction is very variable. • Early symptoms. – Frequecy, nocturia, hesitancy and poor stream, or of secondary urinary infection – Such symptoms may be tolerated for many years, and patients may not complain at all untill retention of urine occurs • Induration about a stricure • Rectal examination: • atony of the anal sphincter • Enlargement of the prostate • Urinary stream (force and caliber) • Retention of urine • Acute retention: with a apparently sudden and distressing inability to pass urine. The bladder is tender and tensely distended, and the patient is well aware of a desperate urege to pass urine • Alternatively, the bladder may undergo gradual progressive dialation and this results in painless chronic retention and eventually overflow incontinence. • The stretched and weakened detrusor gives way in places to form diverticulae, which come to contain stagnant infected urine and often urinary stones. • This insidious presentation is more serious since bladder function may not recover completely. • Neglected obstruction • More importantly though, untreated obstruction can lead eventually to bilateral upper tract obstruction and consequent renal impairment (obstructive uropathy). • Patients may then present for the first time with signs of established chronic renal failure with polyuria, anorexia, vomitting, hypertension and impaired consciousness. Investigation • This depends on the stage at which the patient presents • Patient presenting with early outflow symptoms require careful assessment to exclude other causes of similar symptoms, especially bladder cancer and prostate cancer: • Urinalysis and digital rectal examinaltion are essential • Uroflowmetry gives an objective measure of poor flow • Ultrasound can be measure incomplete bladder emptying sensitively • A plain film is useful to exclude stones • If there is incomplete bladder emptying, serum creatinine should be checked and an upper tract ultrasound examination performed since consevative management may be contraindicated. Treatment
• Patients presenting with acute retention require
relief with urethral (or percutaneous suprapubic catheterisation • Most will subsequently require surgical treatment, but if there is no good preceding history of out flow symptoms then a trial removal of catheter may be followed by a return to voiding, allowing elective assessment of the bladder outflow. Medical treatment • Alpha-adrenergic blockers inhibit contraction of the prostate capsule and bladder neck, which can improve mild symptoms. • 5α-Reductase inhibitors can cause gradual shrinkage of the prostate, but their place in treatment is not established Surgery
• Transurethral prostatic resection (TURP)
remains the current standard treatment • Retropubic (open) prostatectomy is reserved for very large glands • Alternative “minimally invasive” treatments: – Tranurethral laser coagulation/resection – Transurethral microwave thermotherapy/TUMT – Prostate stents – Balloon dilatation Urethra stricture Causes • Stricture results from contraction and fibrosis occurring during healing of a urethral injury or after an episode of inflammation • Traumatic – Major pelvic fracture:urethral rupture – Perieal trauma: a fall astride – Iatrogenic: insrumentation or catheterisation • Infective and inflammatory – Gonococcal urethritis – Non- specific urethritis Diagnosis • Urethral stricture should be suspected in a young man with poor urine flow. • The urine flow rate has a characteristic plateau appearance • The diagnosis is confirmed by urethroscopy and further assessed by contrast urethrography. Complications of urethral stricture • Complications are generally those of long- term bladder outflow obstruction: • Commom – Urine infection – Epididymitis • Rare – squmous carcinoma Treatment • Urethral dialation has been in used for centuries but provides temporary relief only and has to be repeated at intervals • Endoscopic incision (optical urethrotomy) may be curative but often has to be supplemented by intermittent self- catheterisation by the patietnt. • Formal urethroplasty (open urethral repair) is required for long, recurrent or dense strictures Case 1 • A man aged 74 years presents with a history of passing no urine for 12 hours. He denies previous urinary symptoms but on direct questioning admits that he has needed to get out of bed two or three times each night to pass urine for several years. He is now very restless and uncomfortable, with a constant urge to pass urine: Is it true???Why? • Catheterisation should be deferred until renal function has been assessed by urgent blood biochemistry • The bladder should be decompressed slowly to avoid causing heavy heamaturia • The retention may have been precipitated by antidepressant medication • The most likely cause is benign prostatic enlargenmen • Blood should be taken for PSA assay within 24 hours Answers • False. This presentation is of acute retention and early relief by catheteration takes priority over investigation • Controversial . Although bleeding can occur from the bladder after decompression by catheterisation, this is more common after chronic retention and furthernore, is not prevented by slow decompres-sion. But in clinical practice we are warmed to do in this way. • Yes Any drug with anticholinergic action can precipitate retention • True. • False. The PSA level may be spuriously elevated soon after retention or catheterisation. About prostate cancer. True or false??why? • Prostate cancer is present in most men over 80 years age • A serum PSA greater than 100ug/litre suggests skeletal metastases • A serum PSA of 15ug/litre is diagnositic of prostate cancer • Early disease can often be cured by bilateral orchiectomy • Abnormal uptake on bone scan can be disregarded if radiographs of the same area are quiet normal Answers • Ture. But men have an asymptomatic microscopic focus • True. 80% will have a positive bone scan • False. A PSA at this level is probably caused by benign hyperplasia only. • False.Orchiectomy and other types of hormonal manipulation can produce useful remission of advanced disease but are never curative. Such treatment are not indicated for early asumptomatic disease. • False. Although bony secondaries are usually sclerotic, this combination is also diagnostic of metastasis Question about Ureteric obstruciton: ture or false? Why? • is most often caused by calculus • If the plain KUB radiograph is normal, it cannot be caused by calculus • May be asymptomatic • Usually causes an increase in blood urea • Should always be relieved when complicating advanced pelvic malignancy answers • True. 90% of cases are caused by stone • False. Not all urinary stones are radiopaque • Ture. Especially when of gradual onset • False. If the other kidney is normal and unobstructed, as is usually the case, blood biochemistry is unchanged. • False. Each individual patient should be considered carefully, but it is often considered wrong to relieve a painless terminal complication and then expose the patient to a painful death from other cause in some country but not in China. Case 2 • This 83-year-old man has started wetting his bed at night, and has anorexia and weight loss. You have his blood biochemistry results, and the report of an abdominal ultrasond examination. • Look at the results, and then explain to the patient what treatment you recommend • Blood biochemistry: Na 135 K3.8 Urea 42 Creatinine 280 • Ultrasound report: Liver, gallbladder, spleen unremarkable. There is gross bilateral hydronephrosis and hydroureter. The bladder is hugely distended, although the patient has just voided, and the bladder volume is established as 3500ml Discuss of case 2 • He has overflow incontinence secondary to bladder outflow obstruction, complicated by obstructive renal failure. • You should explain the need for prompt urethral catheterisation, both to relieve the renal obstruction, and to treat the incontin- ence • You should explain the need for close (probably in-paitient) monitoring of fluid balance as an obligatory diuresis is likely to occur, requiring fluid replacement. You should consider explaining that the bladder is unlikely to recover, and long- term catheteration or intermittent self- catheteration may be needed Case 3 • A man of 44 years present with a 3year history of increasing frequency of micturation. For the past year he has needed to wake about five times each night to pass urine. He admits that the stream of urine has become weaker and prolonged. About 6years ago he was involved in a fight and was kicked in the perineum. • Examnation shows a mild phimosis, rectal examination reveals a normal prostate. Urinary flow rate is a maximum of 4ml per second, and it takse 90 seconds for him to pass 200ml. Questions • What is the most likely diagnosis? • What other investigation should he have? • How might he be treated initially? • Should he have a circumcision and is so why? Answers • Symptomatic benign prostatic hyperplasia is only occasionally seen at this age, with funcitonal bladder neck obstruction being rather more frequent. This history and findings are, however, most suggestive of obstruction caused by traumatic urethral stricture. • A midsteam urine specimen should be collected for culture, since obstruction often complicated by infection. The probable diagnosis is best confirmed by cystoscopy (flexible or rigid), although the actual length and position of any urethral stricture may be better defined by contrast urethrography. Urinary tract ultrasound may be indicated if there is evidence of incomplete bladder emptying, and plain abdominal radiograph will exclude bladder calculus. • Urethral stricture can be mannaged initially by dialation with urethral sounds, but endoscopic incision of the stricture (optical urethrotomy) has better long term results. • Circumcision should be avoided if possible, since long or recurrent stricture may come to require urethroplaty and the preputial skin may be required to form a urethral patch